When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?
Determine apical pulse rate and rhythm.
Observe color and amount of urine.
Compare muscle strength bilaterally.
Assess strength of deep tendon reflexes.
The Correct Answer is A
Choice A reason: This is the most important intervention because a high serum potassium level can cause cardiac dysrhythmias, which can be life-threatening. The nurse should monitor the client's heart rate and rhythm closely and report any changes or abnormalities to the healthcare provider.
Choice B reason: This is not the most important intervention because the color and amount of urine are not directly related to the serum potassium level. The nurse should assess the client's renal function and fluid balance, but these are not the priority assessments.
Choice C reason: This is also not the most important intervention because the muscle strength is not the most sensitive indicator of the serum potassium level. The nurse should evaluate the client's neuromuscular status and watch for signs of weakness or paralysis, but these are not the priority assessments.
Choice D reason: This is another incorrect intervention because the deep tendon reflexes are not the most reliable indicator of the serum potassium level. The nurse should check the client's reflexes and note any hyperreflexia or hyporeflexia, but these are not the priority assessments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Applying lubricant to the cannula tubing is not the best intervention as it may cause irritation or infection of the nasal mucosa. The nurse should use water-soluble gel or saline spray to moisten the nasal passages if needed.
Choice B reason: Placing padding around the cannula tubing is the best intervention as it prevents friction and pressure on the skin. The nurse should use soft materials such as gauze or foam to cushion the tubing and check the skin integrity frequently.
Choice C reason: Decreasing the flow rate to 1 L/minute is not an appropriate intervention as it may compromise the client's oxygenation. The nurse should maintain the prescribed flow rate and monitor the client's vital signs and oxygen saturation.
Choice D reason: Discontinuing the use of the nasal cannula is not an option as it may endanger the client's life. The nurse should continue the oxygen therapy as ordered and provide comfort measures and education to the client.
Correct Answer is A
Explanation
Choice A reason: This is the most important intervention because a high serum potassium level can cause cardiac dysrhythmias, which can be life-threatening. The nurse should monitor the client's heart rate and rhythm closely and report any changes or abnormalities to the healthcare provider.
Choice B reason: This is not the most important intervention because the color and amount of urine are not directly related to the serum potassium level. The nurse should assess the client's renal function and fluid balance, but these are not the priority assessments.
Choice C reason: This is also not the most important intervention because the muscle strength is not the most sensitive indicator of the serum potassium level. The nurse should evaluate the client's neuromuscular status and watch for signs of weakness or paralysis, but these are not the priority assessments.
Choice D reason: This is another incorrect intervention because the deep tendon reflexes are not the most reliable indicator of the serum potassium level. The nurse should check the client's reflexes and note any hyperreflexia or hyporeflexia, but these are not the priority assessments.
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